Healthcare Provider Details

I. General information

NPI: 1912067828
Provider Name (Legal Business Name): PREVENTIVE MEDICAL CENTER OF MARIN INC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 12/11/2006
Last Update Date: 09/29/2023
Certification Date: 09/29/2023
Deactivation Date:
Reactivation Date:

III. Provider practice location address

4340 REDWOOD HWY STE AA
SAN RAFAEL CA
94903-2121
US

IV. Provider business mailing address

4340 REDWOOD HWY STE A-22
SAN RAFAEL CA
94903-2121
US

V. Phone/Fax

Practice location:
  • Phone: 415-472-2343
  • Fax: 415-472-7636
Mailing address:
  • Phone: 415-472-2343
  • Fax: 415-472-7636

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code261QP2300X
TaxonomyPrimary Care Clinic/Center
License Number
License Number State

VIII. Authorized Official

Name: DR. ELSON M HAAS
Title or Position: OWNER MEDICAL DIRECTOR
Credential: MD
Phone: 415-472-2343